Isr J Psychiatry Relat Sci - Vol. 49 - No 4 (2012) Paraphilic Diagnoses in DSM-5

Richard B. Krueger, MD, and Meg S. Kaplan, PhD

Columbia University, College of Physicians & Surgeons, Department of Psychiatry, and Sexual Behavior Clinic, New York State Psychiatric Institute, New York, New York, U.S.A.

scheduled for publication in May of 2013 (2). Major changes are being proposed for both the specific criteria Abstract and for the overall organizational structure of The Background: The DSM-5 has been under revision since Diagnostic and Statistical Manual of Mental Disorders 1999 and is scheduled for publication in 2013. This article (1, 3) . The paraphilias are no exception to these changes will review the major proposed modifications of the (4). Significant controversy has surrounded both the Paraphilias. DSM-5 (5) and its proposed revisions for paraphilic diagnoses (6). This article will review the major revi- Method: The information reviewed was obtained from sions proposed for the paraphilic disorders as well as PubMed, PsychInfo, the DSM-5.org website and other some of the significant criticisms. sources and reviewed.

Results: Pedohebephilia, Hypersexual Disorder and Paraphilic Coercive Disorder are new proposed diagnoses. Method Paraphilias have been assigned their own chapter in DSM- A literature search was conducted on PubMed and 5 and a distinction has been made between Paraphilias PsychoInfo databases from the year 1990 through April and Paraphilic Disorders. Victim numbers have been of 2011. The search used search terms of “paraphilias,” included in diagnosis of paraphilias that involve victims “exhibitionism,” “voyeurism,” “frotteurism,” “sadism,” and remission and severity measures have been added “masochism,” “fetishism,” “transvestic fetishism,” “para- to all paraphilias. Transvestic Disorder can apply to males philia-related disorder,” “hypersexual,” “hypersexuality,” or females, Fetishistic Disorder now includes partialism, “sexual addiction,” “sexual compulsion,” “paraphilic and Sexual Masochism Disorder has Asphyxiophilia as coercive disorder,” “hebephilia,” “pedophilia,” and “para- a specifier. philic rape.” Titles and/or abstracts were inspected to ascertain if the article contained criticisms relevant Limitations: This study is based on a literature review and to the current DSM-5. Relevance was ascertained by influenced by the knowledge and biases of the authors. any mention of any of the Diagnostic Manuals, or by Conclusions: The Paraphilic Disorders Section of the reference to criticism or diagnostic criteria in their title DSM-5 represents a significant departure from DSM- and/or abstracts. In addition, the authors drew upon, in IV-TR. an unsystematic way, secondary references, textbooks, textbook chapters, and newspaper articles that com- mented on the DSM or DSM-5. Finally, the DSM-5. org website was consulted extensively. Inevitably, the selection of articles was influenced by the experience Background and biases of the authors, but an attempt was made The revision of The Diagnostic and Statistical Manual to present both positive and negative criticism on the of Mental Disorders began in 1999 (1) and DSM-5 is major issues in a balanced way.

Address for Correspondence: Richard B. Krueger, MD, Medical Director, Sexual Behavior Clinic, New York State Psychiatric Institute, 1051 Riverside Drive, Unit #45, New York, New York 10032, U.S.A. [email protected]

248 Richard B. Krueger and Meg S. Kaplan

Results First (10) opined that this distinction “has strong conceptual and practical advantages” (p. 250). Wakefield Proposed Changes Affecting All or Several of the (12) referred to this as a “welcome but more a termi- Paraphilias nological revision rather than an actual change in the criteria” (p. 203) and noted that this distinction had 1. Proposed Separate Categorization for the been implicitly recognized since DSM-III-R. Paraphilias Others have been more critical. Moser, writing A significant proposed change is that the diagnostic about the non-criminal paraphilias (13), suggested category of Paraphilias has been moved from within that “ascertainment” would not prevent misuse of these the section of Sexual and Gender Identity Disorders paraphilic diagnostic categories, and the impression in DSM-IV-TR to its own separate section, coequal that one had been “diagnosed” with such a paraphilia. with other disorders. Two new diagnoses, Paraphilic Fedoroff (14) wrote that if an ascertained paraphilic Coercive Disorder and Hypersexual Disorder, have interest was not causing any dysfunction, then it was been proposed for consideration for inclusion in the not a mental disorder and should not be contained in appendix (4, 7). the DSM at all. Further, he wrote that once a person’s paraphilic interest was ascertained, it would be difficult 2. Paraphilias vs. Paraphilic Disorders to imagine that he would not be considered as being A second change that affects all of the paraphilias is diagnosed. O’Donohue (15) questioned the meaning the distinction between paraphilias and paraphilic and implications of the term “ascertained” and said that disorders. A paraphilia (8) corresponds to the A criteria, its use doubled the psychometric problems of the DSM which define an atypical or deviant sexual interest, and because it would now have to ask questions about the would be “ascertained” according to the A criteria. reliability and validity not only of diagnosis, but also However, to qualify for a diagnosis, the B criteria, which of ascertainment. specify clinically significant distress or impairment, or, in the case of paraphilias which involve a victim 3. Victim Number (exhibitionism, frotteurism, pedophilia, sexual sadism The Paraphilias Subworkgroup suggested another broad and voyeurism) also include a specification that a person change; this involved including a specific victim number has acted on these sexual urges with a nonconsenting in the B criteria for those disorders involving noncon- individual, must in addition be fulfilled. senting persons. Several rationales were given (8). One Blanchard argued that this distinction would be was that since the majority of patients evaluated were useful to researchers in that “It would prevent a para- referred after a criminal offense they were not reliable philia from becoming invisible to clinical science just historians. A reliance on a specific victim number, because it lacks any secondary effect of disturbing the contained in criminal records, would lessen the depen- individual or others” (9, p. 307). Thus, researchers dence on self-report of urges and fantasies. A second could contemplate epidemiological studies of alterna- rationale was that the words “recurrent” and “intense” in tive sexual interest patterns using the DSM-5 A criteria the DSM-IV-TR A criteria had been criticized as being without the necessity that these would be disorders. too vague to be useful (16) and requiring a minimum Further, this new conceptualization addresses some number of victims would increase the certitude in of the concerns raised by groups advocating for those diagnosing these disorders in non-cooperative patients. with paraphilic sexual interests, such as the National This reliance on victim count has been vigorously Coalition for Sexual Freedom, who demand that para- criticized, especially in light of the requirements for data philias be removed entirely from the DSM because their set forth as a precondition for criterion change in the inclusion is stigmatizing, by listing these non-disordered DSM, which require, for a substantial change, that there paraphilias in the “Other Conditions That May Be a be a broad consensus of expert clinical opinion, that Focus of Clinical Attention” chapter of DSM-5 (10). there be empirical support from a number of validators, Indeed Wright (11) described a child custody case in and that such change should not be based solely on which the proposed revisions for DSM-5 were cited and reports from a single researcher or research team (17). a mother, involved with sexual sadism, was allowed to First (18) reviewed the proposals for including a specific keep her children. victim count, and found that for all of the disorders,

249 Paraphilic Diagnoses in DSM-5 only a single study (20) was cited as justification for of a paraphilia and these scales offer a significant step adopting a diagnostic threshold involving victims. towards providing such scales. Another line of criticism against victim number has been that a requirement for a minimum number of victims would result in false negatives. In the case Proposed Changes Affecting Specific of Pedohebophilia, for instance, an individual who Paraphilias had abused only one child for at least 6 months would not necessarily make criteria for this diagnosis under 1. Pedohebephilic Disorder DSM-5 (15). O’Donohue (15) also raised the question Perhaps the most controversial of the proposed para- of why the unit of analysis was the victim, as opposed philic diagnoses in DSM-5 concerns Pedophilia. The to the number of abusive incidents. On the other hand, Paraphilias Subworkgroup has recommended renaming Wakefield (12) expressed that setting such a thresh- Pedophilia to Pedohebephilic Disorder and expanding old was a positive step against making false positive its definition to include hebephilia, which is a sexual diagnoses. desire for early pubescent children. In DSM-IV-TR, Pedophilia referred to an interest only in a prepubescent 4. Remission child or children, and the proposed revision for DSM-5 The term “In Remission” has been added to the diag- would expand this to include pubescent children. nostic criteria for each of the paraphilias. In fact, DSM- Blanchard set forth the rationale for these changes IV-TR allowed for the use of “in partial remission” or (9, 24, 25) which were also listed on the DSM-5 website “in full remission” for most disorders (20, p. 2), but these (26). The principal reasons given were: hebephilia and were not specifically included as part of the diagnostic pedophilia are similar, with both involving attraction criteria for any of the paraphilias. The designation of to immature persons; many men do not differentiate remission also can only be given if the patient is in an between prepubescent and pubescent children; many uncontrolled environment; otherwise, a notation is individuals who offend against pubescent children are made that the patient is in a controlled environment. being diagnosed as pedophilic anyway; and this change would harmonize the DSM with the ICD definition of 5. Severity Measures Paedophilia, which is “A sexual preference for children, DSM-5 has required dimensional ratings for all of its boys or girls or both, usually of prepubertal or early disorders (21-23) and these have been added for the pubertal age” (ICD-10 F65.4. . .)” (26). paraphilias. Both clinician-rated and patient-rated Some critics have asserted that such a definition severity measures have been suggested. The clinician pathologizes legal behavior, where, in much of the rating scales involve a rating over the past two weeks, world, legal consent would permit sexual relations with comparing paraphilic with normophilic interests and pubescents, and that psychiatry is becoming an agent behaviors. These ratings range from 1 (mild), where of social control (27, 28). Frances and First (29) wrote the paraphilic sexual fantasies, urges or behaviors are that the merger of pedophilia and hebephilia within the weaker than normophilic sexual interests and behav- same diagnosis could be justified if there was empiri- iors (8), to 4 (very severe) where the paraphilic urges cal evidence demonstrating that across high-priority completely replace normophilic sexual interests and validators, such as familial aggregation, diagnostic behaviors. In concert with the rest of DSM-5, there stability, course of illness or response to treatment, are also patient self-rating measures (8). these two conditions were identical; unfortunately, they These severity ratings represent a substantial change could find no such studies. They also pointed to several from DSM-IV-TR, where there were guidelines for studies (30-32) demonstrating that sexual arousal to severity that could be applied to all of the diagnoses, pubescent individuals was common and within the but which only consisted of “mild,” “moderate,” and range of normality. Finally, they suggested that because “severe” (20, p. 2). These new dimensional questions of the blurry dividing line between pubescent and are clear and offer reasonable metrics which could help prepubescent children, diagnosis would become more quantify the degree of severity of a paraphilia and which difficult and diagnostic reliability compromised. Others could be psychometrically validated. In fact, there are from the United States have argued that the extension currently no validated instruments for rating the severity of pedophilia to hebephilia is a back-door way of trying

250 Richard B. Krueger and Meg S. Kaplan to expand the scope of diagnoses that can be utilized in Finally, it should be noted that there are two ongo- civil commitment procedures (where individuals with ing studies, not funded or officially sanctioned by the a severe history of sexual offenses can be committed American Psychiatric Association (39, 40), which should indefinitely to a treatment facility)(12, 33). Wakefield produce data to compare the DSM-IV-TR diagnostic (12) opined of this suggested change, “In sum, the criteria with the proposed DSM-V criteria. These stud- hebephilia proposal is probably the Workgroup’s most ies, it should be noted, represent a substantial improve- flawed and blatantly over-pathologizing paraphilia ment over the studies supporting previous manuals. proposal. Hebephilia as a diagnosis violates the basic These studies represent a significant improvement over constraint that disorder judgments should not be deter- prior studies for the paraphilias in the DSM. Blanchard mined by social disapproval. This is a case where crime (41) summed the total of all patients studied in con- and disorder are being hopelessly confused (p. 206).” junction with prior revisions of the DSM involving Blanchard responded to these criticisms, saying that the paraphilias; there were only three. criteria as they stand in DSM-IV-TR “would exclude from diagnosis a sizable proportion of those men whose 2. Paraphilic Coercive Disorder strongest sexual feelings are for physically immature The DSM-5 Subworkgroup has proposed Paraphilic persons” and reviewed substantive research which Coercive Disorder for inclusion in the appendix. This supports this proposed change (34, p. 334). disorder (42) would apply to men who obtained sex- Another novel aspect of the proposed criteria for ual arousal from sexual coercion and were not sexual Pedohebephilic Disorder is the inclusion of child sadists. The suggestion of this disorder for the DSM is pornography in the criteria. According to the DSM-5 not new; in 1985 the DSM-III Workgroup proposed website, the rationale for the addition of this is that the diagnosis of paraphilic rapism (43), which was “Some research indicates that child pornography use extensively criticized at the time. may be at least as good an indicator of erotic interest in This proposed disorder has continued to draw criti- children as ‘hands-on’ offenses” (26). A 2006 study by cism, especially in the United States, where it is seen Seto, Cantor and Blanchard (35) compared phallometric as a diagnosis with little empirical support and one testing on 100 offenders arrested for charges involving which could enable civil commitment, by expanding child pornography with 178 sex offenders with child the number of diagnoses which could be used as a basis victims and demonstrated significantly greater arousal for commitment (44, 45). Indeed, a vote taken follow- to children on the part of the child pornography offend- ing a debate before forensic psychiatrists in Arizona in ers than on the part of the offenders against children. It October of 2010 overwhelmingly decided against inclu- is also makes intuitive sense that a person’s pornography sion of the new paraphilic coercive disorder (along with preference may be a more accurate indicator of his pedohebephilia and hypersexual disorder) in the DSM-5 underlying sexual interest than other factors because (44). On the other hand, Stern (46) suggested that this “people opt for pornography that corresponds to their diagnosis would replace the misuse of Paraphilia Not sexual interests” (36). However, First (10) analyzed Otherwise Specified diagnoses with specific criteria, this criterion and suggested that its inclusion as a B which would lessen the likelihood of inappropriate criterion, where use of it could lead to severe nega- diagnoses. Research continues to suggest that there tive consequences because of its illegal nature, made are unique features to sexually coercive men (47) and it dependent on the particular legal system in which field trials of this disorder examining both diagnostic a patient might reside. This jurisdiction might not reliability and validity are underway (40). consider certain sorts of child pornography, such as virtual child pornography, where rendering did not 3. Hypersexual Disorder involve any actual children, as illegal, and thus would A third controversial diagnosis suggested by the DSM-5 not allow the person to fulfill the negative function of Paraphilias Subworkgroup is Hypersexual Disorder criterion B. Further, he pointed out this criterion was (48). This disorder, which is now listed in the Sexual based on one study from one group, which may not at Dysfunctions part of the DSM-5 website and which all be typical (10). Other studies have found that only a is being considered for the appendix (49), identifies minority of individuals arrested for child pornography recurrent and intense normophilic sexual fantasies, meet criteria for pedophilia (37, 38). urges, and behavior as being pathological if they are

251 Paraphilic Diagnoses in DSM-5 excessively time consuming, in response to stress or 6. Sexual Masochism Disorder dysphoric moods, cannot be controlled, disregard the Sexual Masochism, aside from the generic changes risk of harm to others and cause distress or impairment described earlier to the paraphilias, has remained largely in functioning. unchanged, with the exception that the Specifier “With This disorder has evoked much criticism. Zonana Asphyxiophilia (Sexually Aroused by Asphyxiation)” (50) noted that hypersexuality was a symptom, not a was added and the phrase “Real, not simulated” was disorder, in DSM-IV, and both he and Fedoroff (14) deleted from the criteria, as it did not appear to add opined that these criteria could easily apply to almost any real distinction and no rationale could be found for any adult who was sexually active. Halpern (51) asserted this in the literature (60). Hypoxyphilia, or the produc- that this diagnosis medicalized aberrant sexual activity, tion of sexual excitement by asphyxia, was found in was redundant, lacked an empirical base, and would several studies on Sexual Masochism; the Paraphilias result in false positive diagnoses. Moser (52) criticized Subworkgroup discussed this and asked for an analysis this diagnosis as being “based on faulty and inconsistent of the literature by Hucker (61, 62). This concluded logic, imprecise criteria, historical inaccuracies, and that individuals engaging in this behavior obtained poorly conceived constructs” (p. 229). sexual arousal mainly through restriction of breathing, originally termed “asphyxiophilia” by Money (63) and 4. Transvestic Disorder therefore this specification was added. This change DSM-5 has (53) proposed changes in the criteria for this was criticized by Fedoroff (14) as failing to distinguish disorder so as to allow females to be so diagnosed and between those who were aroused by being asphyxiated added specifiers of fetishism (being sexually aroused and those who were aroused by asphyxiating others. by fabrics, materials, or garments), autogynephilia Shindel and Moser (64), citing lack of evidence that (being aroused by the thought or image of oneself as sexual masochism was harmful and asserting that female), and autoandrophilia (being aroused by the continuing the diagnosis in the DSM continued the thought or image of self as male). Swedish health officials harmful labeling effect of this disorder, have called for removed transvestism from the official list of diseases its frank exclusion from the DSM. and mental disorders (54) and others have called for its removal from the DSM because they do not believe it is a mental illness (55). However, the World Professional Limitations Association for Transgender Health (WPATH), after The main limitation of this study is the fact that it is a a consensus process, advised retaining the diagnosis, literature review, which is influenced by the knowledge albeit with some change in the criteria (56). and biases of the authors. Additionally, the paraphilias have not had the funding, research base, or develop- 4. Fetishistic Disorder ment of scientific studies that other areas of psychiatry Fetishistic Disorder has undergone modest changes, have enjoyed. Thus, many of the studies upon which the expanding the diagnosis to include an interest in non- knowledge base of the paraphilias is based are drawn erogenous body parts in addition to an interest in non- from samples of convenience, not from epidemiologi- living objects. Kafka (57) reviewed the literature for cally sound samples, and subject to bias. Finally, much fetishism and found that for most of the history of this of the data for this study was retrieved from the DSM-5 disorder it had been characterized by persistent arousal website, which has been revised and will continue to be to both non-living objects and nonerogenous body revised as new information and feedback on the proposed parts (referred to as partialism). Accordingly, Fetishism criteria is obtained and responded to. Nevertheless, this was revised from its previous criteria which specified article represents a comprehensive “snapshot” of the cur- sexual arousal only towards nonliving objects to include rent major proposed changes in the DSM-5 Paraphilic “sexual arousal from either the use of non-living objects Disorders at a late stage in their development. or a highly specific focus on non-genital body part(s) . . .” (58). Although this disorder has not received as much criticism as others, some have argued for its Conclusions removal from the ICD-10 (59) because it stigmatizes The Paraphilic Disorders Section of the DSM-5 repre- those practicing these behaviors. sents a significant departure from DSM-IV-TR. Many

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